Elsevier

Thoracic Surgery Clinics

Volume 22, Issue 4, November 2012, Pages 539-543
Thoracic Surgery Clinics

Patients' Perspective in the Surgical Decision-Making Process

https://doi.org/10.1016/j.thorsurg.2012.07.001Get rights and content

Introduction

There are 2 types of clinicians who allow patients to decide their management plan: the worst of doctors and the best of doctors. The paradox is easily explained. The first is the uninformed doctor, who is unaware of the available options and corresponding benefits and risks and therefore relies on the patient to decide what he or she thinks is preferable. The second is the fully informed doctor with a thorough knowledge and grounding of the subject who is able to detail the management options and corresponding benefits and risks and has the confidence to inform the patient when he or she does not know the answer (because there is no available evidence) to guide the decision and helps the patient decide the best management option. Most clinicians tend to practice safely in the middle by following recommendations (of others) published in textbooks or, more often, national or international guidelines (written by others) that are designed for the population as a whole rather than the person who is sitting on the other side of the clinician’s desk.

Unfortunately, patient perception in the surgical decision-making process is not a well-researched field in thoracic surgery, and much of what is written in this article is based on the author’s experience quantifying benefits and risks on a wide range of medical and surgical procedures as an editor of a textbook of medicine and surgery,1 understanding clinical decision making at empiric levels as a qualified medical statistician, awareness of the difficulties in appreciation and communication of benefits and risk as a final-year undergraduate teacher at Imperial College Medical School in London, and aware, as a practicing surgeon, of the difficulties patients face when attempting to come to terms with major life-changing decisions.

Section snippets

Surgical decision making

At the most basic level, surgical decision making seems simple: the benefits and risks of each procedure are weighed and a decision undertaken in favor of the option whereby the benefit outweighs the risk. The difficulties arise in this decision, however, when trying to establish the size of the benefit against the size of the risk. To take things one step further, it is not simply the benefit or risk as quantified by a number (eg, a 28% risk of a recurrence of a spontaneous pneumothorax after

Understanding and Conveying Information on Risk

If surgeons subscribe to the notion that patients should be allowed to make their own independent decision regarding benefits and risks, he or she still needs to quantify it to facilitate the correct interpretation. An intermediate understanding of statistics is usually required, a subject often poorly taught in medical school and not usually covered in surgical training. The most basic level is the ability to convey percentage risk. For example, the risk of in-hospital death after lobectomy is

Patient Expectations

Although much of this article has focused on the decision-making process and on doctors facilitating such an approach, occasionally, patients do not want to engage in a decision-making process. This is usually based on expectations that the patient is seeking a medical consultation and wants the doctor to make a recommendation, and clearly the simplest and easiest way is to comply. One wonders, however, if it is the best or correct way, because patients often assume that decisions are made at a

Summary

At the most basic level, surgical decision making involves an assessment of benefits against risk. However, in practice, it may not always be possible to quantify benefits; patients may not have the same perception of value or risk and, in many cases, there is uncertainty or equipoise. In this setting, patients’ perceptions are critical to the management decision. Barriers can arise if surgeons are unable to effectively convey information on benefits and risks or are unwilling to offer

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References (19)

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